A victim of spousal abuse comes to the emergency department for treatment of a broken nose. She appears hypervigilant and anxious and admits to sleep disturbance when the nurse questions the dark circles under her eyes
She reluctantly tells the nurse the abuse usually occurs when the husband has been drinking, although she concedes he is always jealous and controlling. She is a stay-at-home mother of two preschool children. The family has lived in this town for 1 month. The patient states she has fleetingly considered suicide but must stay alive to care for her children and work her way out of the abusive relationship. She denies having had the desire to kill her husband and has no history of violence. The nurse should document in the medical record that: (Select all that apply.) a. signs of high anxiety and chronic stress are present.
b. the patient relies on the perpetrator for basic needs.
c. the patient is isolated from individual and community support.
d. suicide risk is high and merits inpatient admission.
e. the immediate risk of revenge homicide is low.
f. a safety plan should be constructed before discharge.
A, B, C, E, F
The patient demonstrates and reports signs of stress, including anxiety and sleep disturbance. She is dependent on the spouse because she is unemployed, and she has no support-system access. She is new in town and not connected to peers or community resources. Few risk factors for suicide or homicide are noted; the patient is future-oriented, and her desire to be there for the children mitigates her fleeting thoughts of suicide. A safety plan is indicated because the spouse has injured her and has a pattern of violence, substance abuse, and other risk factors.
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